Overcoming barriers to pediatric intensive care in low-resource settings: an institutional experience from Northeast India

Abstract

Developing pediatric intensive care units (PICUs) in resource-limited regions presents several challenges, including significant resource constraints, a shortage of trained personnel, and a lack of standardized care protocols. Prioritizing skills and knowledge development for healthcare professionals, selecting effective yet affordable equipment, and strong leadership have been identified as essential for establishing sustainable pediatric critical care services in low- and middle-income countries (LMICs). In this article, we describe the practical, phased approach undertaken in a charitable hospital setting in Northeast India to establish a PICU, highlighting adaptability, institutional commitment, patient team building, and systematic record-keeping in overcoming these challenges. The lessons drawn from this experience can offer valuable insights for similar healthcare settings in LMICs, demonstrating that high-quality pediatric critical care can be achieved even in resource-constrained environments.

Key messages.

• A phased, context-adapted strategy enabled the successful establishment of a Level 3 pediatric intensive care unit (PICU) in a resource-limited setting in Northeast India.

• Institutional commitment, interdisciplinary collaboration, and prioritization of workforce training were critical to overcoming infrastructural and human resource barriers.

• This experience offers a replicable model for strengthening pediatric critical care in other low-resource regions, highlighting the importance of leadership, local adaptation, and system-building.

Introduction

Pediatric intensive care unit (PICU) services in resource-limited regions face challenges, including inadequate healthcare infrastructure, a shortage of specialized personnel, and the absence of standardized care protocols, complicating optimal care delivery (Slusher et al. 2018, Olatunji et al. 2024). Studies from low- and middle-income countries (LMICs) emphasize the critical need for pediatric intensivists, trained critical care nurses, essential medicines, and life-saving equipment. In many LMICs, pediatric intensive care is frequently delivered by general pediatricians posing challenges in standardizing care and building structured critical care systems (Slusher et al. 2018). Addressing these gaps requires coordinated efforts from governments, healthcare providers, academic institutions, and global stakeholders (Olatunji et al. 2024). In India, while PICUs in metropolitan cities meet high-income country standards (Slusher et al. 2018), they remain scarce in underserved areas. The Indian Academy of Pediatrics (IAP) has developed guidelines for establishing Levels 2 and 3 PICUs (Khilnani et al. 2002, 2020), but implementing these standards in under-resourced regions faces limitations such as limited specialists, manpower, finances, and infrastructure.

Nagaland, a northeastern state in India, exemplifies the difficulty of establishing specialized healthcare services. With a population of 2.2 million (2011 Census), projected to reach 4.53 million by 2025 and 71.1% of its people living in rural areas (Office of the Registrar General & Census Commissioner, India 2011), the state faces significant healthcare demands. The under-five mortality rate in Nagaland has been reported as 34.8 per 1000 live births (India State-Level Disease Burden Initiative Child Mortality Collaborators 2020). More recent mortality estimates from the Sample Registration System (SRS) 2021 are not available for Nagaland; however, Assam, the only northeastern state with SRS 2021 data, reported neonatal, infant, and under-five mortality rates of 23, 34, and 37 per 1000 live births, respectively (Office of the Registrar General & Census Commissioner India 2025), providing a representative benchmark for the region. Another major challenge is Nagaland’s low population density, ∼119 persons/km² in 2011, projected to rise to 273 in 2025 (Office of the Registrar General & Census Commissioner India 2011). This scattered population is distributed across hilly terrain with poor transportation infrastructure, limiting access to hospital care for newborns and children. Although the state has 11 district hospitals (Department of Health & Family Welfare, Nagaland), these are typically limited in pediatric and critical care infrastructure. The state’s only medical college became operational in 2024 and remains in its formative phase. Most private healthcare facilities are concentrated in Kohima, the capital city, and Dimapur, the commercial hub, where pediatric critical care is often provided in neonatal intensive care units (NICUs) and adult ICUs, both suboptimal for children outside the neonatal age (Rosenberg and Moss 2004, Murthy et al. 2015).

The author’s institute, established in 2007 as a 200-bed charitable hospital, was the largest health facility in the region. Pediatric critical care was provided in a seven-bed neonatal ICU managed by two general pediatricians, with basic equipment and minimal ventilatory support. The distinction between neonatal and pediatric critical care was not widely recognized, leading to misconceptions that the NICU could accommodate older children as well. Nurses were few, lacked critical care training, and rotated across wards. A fully equipped PICU was not feasible at the time, prompting a phased, sustainable strategy.

Implementation

The decision to develop a PICU at the author’s institute was not a single event but the result of a gradual process. The idea emerged in 2019 with the arrival of a formally trained pediatric intensivist, which reassured the administration that critical care services could be expanded. The intensivist mobilized interdisciplinary collaboration; led small-scale improvements in patient care, including basic nurse training, infection control audits, and hands-on supervision; and built early credibility for the initiative. While these efforts were largely qualitative, the consistent demonstration of improved patient care practices provided credible evidence to the administration to internalize PICU development as a shared institutional priority. Implementation subsequently unfolded across several domains as described below.

Strengthening critical care practices

Recognizing the vital role of nurses in critical care, the unit prioritized strengthening their knowledge through integrated training and patient care, led by a full-time pediatric intensivist. A phased approach, summarized in Table 1, began with recognizing danger signs, vital signs, and using Pediatric Advanced Life Support (PALS) charts.

Table 1.

Timeline of phased PICU development at the author’s institute.

Year	Phase	Key actions
2019	Phase 1: Foundation and early advocacy	Pediatric intensivist initiated PICU development; hospital director provided institutional backing and resource support. Basic training, infection control, manual audits. Demonstrated visible progress in patient care to build trust with administration and secure institutional commitment (qualitative evidence)
2019–20	Phase 2: Early Equipment	HFNC device, CPAP device, defibrillator, borrowed ventilator, ultrasound machine
2020–21	Phase 3: Protocol and QI	CLABSI/CAUTI/VAP bundles, drug protocols, stewardship log
2021–23	Phase 4: Capacity scale-up	Dedicated PICU, teleconsultation, staff stabilization
2023–present	Phase 5: Consolidation	Level 3 accreditation, PIM-3 pilot, nursing fellowship

HFNC, high-flow nasal cannula; QI, quality improvement; CPAP, continuous positive airway pressure; CLABSI, central line-associated blood stream infection; CAUTI, catheter-associated urinary tract infection; VAP, ventilator-associated pneumonia; PIM-3, pediatric index of mortality 3.

Ongoing training included patient monitoring, early warning scores, infection prevention, and hands-on sessions in pediatric and neonatal resuscitation. Ventilator care protocols were enhanced with single-use suction catheters, oral care, humidification, and appropriate sedation. Infection control bundles for central line-associated blood stream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and sepsis were implemented. Designated quality improvement (QI) champion nurses ensured bundle compliance. Collaboration with nursing administration helped retain trained staff in the PICU, promoting continuity and peer mentoring.

Expanding monitoring capabilities and equipment

To enhance monitoring capabilities, initial support came from the adult ICU, which shared electrocardiogram leads, end-tidal CO₂ modules, invasive blood pressure transducers, ventilators, and a portable ultrasound. A dedicated supply of consumables was gradually built. Mechanical ventilation was supervised by the pediatric intensivist, who also conducted structured hands-on training for nurses and junior faculty in ventilator setup, troubleshooting, and patient-specific adjustments. Point-of-care ultrasound (POCUS) was initiated for vascular access and bedside cardiac and lung assessments, with an in-house ultrasonologist available for complex scans. A stepwise equipment acquisition strategy prioritized high-impact devices such as a defibrillator, high-flow nasal cannula, and bubble continuous positive airway pressure (CPAP).

Though prioritizing locally available equipment is ideal for maintenance and cost-effectiveness (Slusher et al. 2018), regions such as Nagaland often lack local distributors. Close coordination with procurement teams and vendors ensured a steady supply. Maintaining equipment inventory helped plan replacements, while continuous engagement with the biomedical engineering team enabled prompt troubleshooting and ensured equipment functionality.

Enhancing care through protocols, teleconsultation, and specialized services

To enhance the quality and safety of pediatric critical care, the unit developed standardized protocols for the use of critical care drugs. These were adapted from well-established guidelines, including those from advanced PICUs and drug reference manuals such as the British National Formulary (Joint Formulary Committee 2019). Antibiotic stewardship, implemented with the hospital’s infection control committee, optimized antimicrobial use.

Timely management of complex cases was supported through teleconsultation with subspecialists from external centers, facilitating access to advanced expertise otherwise unavailable locally. These initiatives helped integrate evidence-based practices, address critical service gaps, and lay a strong foundation for sustainable growth in pediatric intensive care. Key challenges faced during the implementation and the corresponding strategies adopted to overcome them are summarized in Table 2.

Table 2.

Challenges in PICU development and strategies to overcome them.

Challenges/obstacles	Strategies adopted to overcome
Limited trained nursing staff and high turnover	Integrated nurse training into daily care; designated QI champion nurses; collaboration with nursing administration to retain staff in PICU
Lack of pediatric-specific equipment and consumables	Stepwise acquisition of high-impact devices (defibrillator, HFNC, CPAP); support from adult ICU (ventilators, monitoring, ultrasound); COVID-19 emergency procurement; dedicated supply planning
Absence of standardized protocols and risk of hospital-acquired infections	Developed and implemented protocols for drug use; introduced QI bundles (CLABSI, CAUTI, VAP); ventilator care protocols; antibiotic stewardship
Limited access to pediatric subspecialists	Used teleconsultation with external specialists; bedside support from in-house adult cardiologist (ECHO) and pediatric surgeon
Financial barriers and discharge against medical advice (DAMA)	Extended family counseling; targeted bill concessions; hospital subsidies; Ayushman Bharat scheme; cost-saving measures (autoclaved equipment, in-house oxygen plant)
Lack of structured data and outcome tracking	Implemented systematic record-keeping for admissions, procedures, and outcomes; used data for planning, accreditation, and fellowship initiation

HFNC, high-flow nasal cannula; QI, quality improvement; CPAP, continuous positive airway pressure; CLABSI, central line-associated blood stream infection; CAUTI, catheter-associated urinary tract infection; VAP, ventilator-associated pneumonia.

COVID-19 and its lasting impact on critical care development

The Coronavirus disease (COVID-19) pandemic, though devastating, served as a pivotal moment in strengthening critical care services within the institution. Emergency funding facilitated the direct supply of ventilators, volumetric and syringe pumps, monitors, and other essential ICU equipment, significantly expanding critical care capacity. The installation of an on-site oxygen plant further enhanced resource availability. These investments not only bolstered intensive care delivery during the pandemic but also laid the foundation for sustained pediatric intensive care development. In the postpandemic period, ventilator capacity was expanded, with select units upgraded to include active humidification systems for neonatal and infant use, and one unit modified for patient transport. These enhancements contributed to the growth and sustainability of the PICU.

Addressing cost of treatment

Cost remains a major barrier to intensive care in resource-limited settings (Gautam et al. 2018, Gehlot et al. 2023). The financial burden often leads to premature discharge against medical advice (DAMA). To address this, transparent and extended communication with families, explaining the nature of disease, expected hospital stay, and available financial concessions were major discussions during rounds. In certain cases, hospital bills were reduced to cover only essential medication and laboratory costs, with the administration playing a key role in facilitating subsidies.

Cost-cutting measures, such as reusable autoclaved equipment and the in-house oxygen plant, further reduced expenses, allowing financial relief for patients in need. Additionally, the government health insurance scheme, Ayushman Bharat, which gained traction in recent years, significantly improved affordability. Internal audits suggested a notable decline in DAMA rates, ensuring that more children receive uninterrupted critical care.

Record maintenance, capacity building, and pediatric intensive care units accreditation

Maintaining detailed records of admissions, outcomes, PICU procedures, microbiology reports, and ventilation days played a key role in resource planning, protocol development, and QI. These data justified staffing and equipment needs and ensured uninterrupted access to essential medications. As the department expanded, it qualified for a postgraduate pediatric training program, strengthening the workforce and promoting education and research. A dedicated eight-bed PICU was established in 2023, 4 years after the initiative began. In 2019, intensive care was provided in a seven-bed NICU that also admitted older children, staffed by 11 nurses who rotated every 3–5 months, limiting continuity and critical care expertise. With the 2023 establishment of a separate PICU (eight beds) and NICU (six beds), nursing strength for intensive care increased to 25, dedicated exclusively to intensive care. The key advance was the shift from rotating general staff to a stable, acuity-based team, ensuring a nurse-to-patient ratio of ∼1:2 for ventilated and 1:3–4 for nonventilated patients, supporting consistent care for critically ill children.

These sustained efforts, anchored by systematic record-keeping and ongoing clinical and educational development, culminated in Level 3 PICU accreditation by the Indian Academy of Pediatrics – Intensive Care Chapter (IAP-ICC), the first in Northeast India. The IAP-ICC contributed indirectly by providing national standards that guided the unit’s gradual alignment with Level 3 requirements. Once these were met, an IAP-ICC team inspected and accredited the unit, a validation that also enabled the launch of a pediatric critical care nursing fellowship. This experience highlights how professional bodies, by setting standards and offering accreditation pathways, can support capacity building in developing settings.

Role of the organization and interdepartmental collaboration

The success of the PICU was made possible by strong hospital support in recruiting and retaining trained staff, allocating space, procuring equipment, establishing essential services such as a blood bank, and providing financial aid for patient care. Administrative backing enabled service expansion, postgraduate pediatric training, and a critical care nursing fellowship, ensuring a stable workforce. Interdepartmental cooperation, particularly early equipment support from the adult ICU, bedside echocardiography by an adult cardiologist, and surgical care from a pediatric surgeon, greatly enhanced patient management. Importantly, infrastructural modifications and PICU development were financed entirely through internal hospital revenue, reinvested from patient care, while grants from corporate social responsibility (CSR) initiatives and the Northeast Council facilitated the creation of other high-end facilities that indirectly supported hospital-wide development. These well-coordinated efforts allowed the PICU to develop without direct reliance on external or government funding.

Observed changes and outcomes

Although long-term outcome tracking was limited initially, improved record-keeping enabled structured documentation over time. Annual PICU admissions rose from fewer than 50 before 2019 to 78 in 2020, 115 in 2021, 152 in 2022, 203 in 2023, and 220 in 2024, alongside increasing critical care interventions, including central line insertions, invasive ventilation, and vasoactive therapy. Children requiring invasive ventilation grew from ∼20 annually before 2019 to over 80 by 2024. Crude mortality was 16.6%, 16.5%, 12.5%, 12.3%, and 13.5% from 2020 to 2024 (unpublished). Prior to structured PICU systems, mortality was thought to be substantially higher, although reliable figures were not consistently documented. Postdischarge mortality and readmission data were not available. Within the PICU, however, most deaths occurred in children with refractory septic shock or severe pneumonia with hypoxemia, but trends and case reviews indicate improved stabilization and survival, particularly in sepsis and respiratory failure. A 2024 internal pilot using PIM-3 in 90 children showed predicted mortality of 11% versus observed 17%, reflecting both increasing patient complexity and limitations of existing risk-prediction tools in our setting.

Achievements/challenges

The establishment of a PICU at our institute highlights both the opportunities and persistent challenges in delivering pediatric critical care in resource-limited settings. Similar to many LMICs, we encountered financial, infrastructural, and human resource constraints, with early care delivered by general pediatricians and NICU staff in the absence of a dedicated PICU. This reflects global findings that the lack of dedicated PICUs, trained pediatric intensivists and nurses, suboptimal nurse-to-patient ratios, and insufficient pediatric-specific equipment significantly compromise care delivery (Slusher et al. 2018, Bjorklund et al. 2022, Olatunji et al. 2024).

Our phased strategy included staff training, protocol development, and staged acquisition of high-yield equipment, approaches shown to improve outcomes in similar LMIC settings (Han et al. 2003, Molyneux et al. 2006, Slusher et al. 2018, Bjorklund et al. 2022, Olatunji et al. 2024). Training was integrated into routine care, beginning with basic life support, danger sign recognition, and PALS-based monitoring, an approach aligning with workforce capacity-building recommendations (Slusher et al. 2018).

Efforts to strengthen clinical systems included the adoption of standardized protocols, infection prevention bundles for CLABSI, CAUTI, and ventilator-associated pneumonia (VAP), and antibiotic stewardship practices. These align with evidence-based best practices in LMIC ICUs (Slusher et al. 2018, Olatunji et al. 2024). Teleconsultations with pediatric subspecialists helped manage complex cases, supporting global recommendations to integrate digital tools and collaborative networks in remote settings (Bjorklund et al. 2022, Alnasser et al. 2024). The COVID-19 pandemic accelerated equipment acquisition, enabling significant improvements in infrastructure and providing a platform for PICU development. However, this momentum was context specific and may not be replicable elsewhere under nonemergency circumstances.

Cost remained a major barrier, with financial constraints contributing to DAMA and postdischarge mortality (Gautam et al. 2018, Madrid et al. 2019, Bosco et al. 2021). Extended counseling, targeted concessions, and government insurance schemes (Ayushman Bharat) helped reduce DAMA, echoing strategies in South India that lowered NICU DAMA rates from 1.6% to 0.6% (Bosco et al. 2021). Systematic record-keeping facilitated QI, resource planning, and policy advocacy, supporting Level 3 PICU accreditation and the launch of a pediatric critical care nursing fellowship, thereby expanding regional capacity.

Enablers and constraints

Several factors enabled successful PICU development. Strong institutional leadership ensured prioritization of resources, staff recruitment, and space allocation. Integrating training into daily care improved workforce capacity and patient outcomes, while shared-resource models, including adult ICU and specialty support, bridged service gaps. COVID-19 emergency funding accelerated equipment acquisition, systematic record-keeping supported QI and accreditation, and teleconsultations enhanced complex case management (Bjorklund et al. 2022, Alnasser et al. 2024). These enablers align with global recommendations emphasizing context-sensitive innovation, administrative buy-in, and strong local leadership (Slusher et al. 2018, Olatunji et al. 2024).

Key constraints remain. Human resource shortages, lack of formal pediatric critical care certification, structured emotional support for staff, and restricted access to simulation or QI leadership training hinder progress (Slusher et al. 2018). Remote location and weak supply chains complicate procurement, and reliance on internal resources limits sustainability. Financial barriers continue to cause DAMA despite mitigation efforts. Additionally, the descriptive and retrospective nature of this report limits its generalizability, and outcomes such as cost-effectiveness remain undocumented. Finally, several successful strategies, such as family counseling and charitable subsidies, were shaped by local cultural values and institutional ethos, which may not translate directly to other settings. These challenges underscore the need for broader structural investment in pediatric critical care across LMICs.

Conclusion

This experience underscores that even in resource-constrained LMIC settings, institutional support, strategic staff training, infrastructure optimization, systematic record-keeping, and interdisciplinary collaboration can enable sustainable PICU development. While much of the literature emphasizes barriers and recommendations, this example offers a practical model for implementation that can inform similar efforts in under-resourced regions and advance global child health goals.

Author contributions

W.R.T. conceptualized and designed the study, led the development of the PICU, and provided inputs in data collection and interpretation and drafting and critical revision of the manuscript. T.A. contributed to data collection, supported the operational aspects of PICU service delivery, assisted in data analysis and interpretation, and provided key inputs in shaping the manuscript. S.K. supported the operational aspects of PICU service delivery, assisted in data analysis and interpretation and provided key inputs in shaping the manuscript. All authors contributed to the critical revision of the article and approved the final version for submission.

Conception or design of the work: W.R.T. Data collection: W.R.T. and TA. Data analysis and interpretation: T.A. and S.K. Drafting the article: W.R.T. Critical revision of the article: W.R.T., T.A., and S.K. Final approval of the version to be submitted: W.R.T., T.A., and S.K.

Reflexivity statement

This study was conducted by two male authors (W.R.T., S.K.) and one female author (T.A.), all senior consultants in the department of pediatrics at the Christian Institute of Health Sciences and Research (CIHSR), Dimapur, with over a decade of experience in general pediatrics. T.A. heads the department and brings a leadership perspective shaped by administrative responsibilities. W.R.T. subspecializes in pediatric critical care and leads the PICU, contributing insights from frontline intensive care in a resource-limited setting. S.K. provides broad clinical experience and institutional continuity.

As long-standing colleagues within the same institution, the authors share a common understanding of the systemic challenges and opportunities in pediatric care delivery. Their dual roles as clinicians and administrators may have influenced their emphasis on feasible, sustainable, and context-specific strategies, which they have consciously reflected upon during the course of this work.

Ethical approval

Ethical approval for this type of study is not required by our institute.

Funding

None declared.

Data availability

This article does not contain any new data beyond what is described in the manuscript. Any data mentioned in this article are part of internal hospital records and are unpublished.